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following the scientific tradition. The standard by which professionals are judged is in relation to their peers (Dimond, 2015; Greenhalgh, 2006). Steel (2006: 57) makes the point that, ‘The development of a more open and evidence-based approach to decision making in healthcare has shown how much personal values influence professional behaviour’. Referring to public health, he warns that science is far from being value free but that it is important to make values clear and decisions explicit (Steel, 2006).
However, the plethora of research published means that professionals need to be able to access, appraise and use research findings to underpin their practice (Greenhalgh, 2006). Given the complexity of research findings, particularly weighted towards quantitative research, this needs to be translated into guidance for practice.
Organisations such as the National Institute for Health and Care Excellence (NICE), National Health Service (NHS) Evidence, Health and Social Care Information Centre, King’s Fund, professional bodies and peer-reviewed journals often mediate and disseminate guidance. The wholesale adoption of the scientific rational model undermines the ‘art’ of professional practice, which encompasses tacit knowledge, narrative-based approaches, service user individuality and professional autonomy.
Greenhalgh (2006) points out that professionals may be profoundly influenced by their own experiences but this may not always be a good basis for making decisions.
It is clearly important to recognise the value of and difficulty in managing both evidence- and narrative-based approaches. For example, an experienced practice nurse may intuitively understand that a woman’s reluctance to have cervical screening is due to past sexual violence. A solely evidence-based practice approach may lead to task-focused care to obtain consent for a cervical smear and omit the importance of human interaction and relationships as an integral part of therapeutic care and may transgress patients’ values (see Chapter 5).
Decision making is influenced by many factors (Box 3.4) including the context and clinical and ethical aspects (Grundstein-Amado, 1992) sitting within wider health and social care and fiscal policies. Access to high-quality information is required from multiple sources, with interplay between them to draw rational conclusions which can be justified.
Box 3.4 Decision-making factors
•
Comprehensive assessment including different stakeholder perspectives•
Wider determinants of health•
Ethical and legal guidance•
Evidence base•
Clinical reasoning•
Options and preferences•
Evaluation•
Accountability•
Safety•
Concordance•
Cost and sustainability51
Principles Informing Professional Practice
Principles of ethical practice
There is a common set of principles that guides ethical practice in health and social care (Beauchamp and Childress, 2013). Decisions are based not just on clinical evidence but also on a set of moral principles. Health itself is enshrined within human rights values (WHO, 2015). In order to do what is right in the particular circumstances, different stakeholders will have different views which need to be considered when making decisions. In the community, value-based decisions impact not only the service users but also their families and social networks and also their property, for example, the impact of converting a living room into a bedroom. Four ethical principles inform decision making in healthcare practice (Beauchamp and Childress, 2013):
•
Respect for autonomy•
Non-maleficence•
Beneficence•
JusticeRespect for autonomy: Individuals have the right to make their own decisions. Professionals must respect the decisions that service users make and ensure their practice is consistent with this (e.g. informed consent).
There are exceptional circumstances where individuals are unable to make decisions; professionals must understand the circumstances and legislation that override this self-rule principle.
Non-maleficence: Practitioners should cause no harm, whether intentional or unintentional. Any resulting harm due to a breach in the duty of care owed to that person may be considered negligence, leaving the practitioner open to a charge of professional misconduct and subject to action for compensation through the courts (Dimond, 2015).
Beneficence: It may seem obvious that care offered should be beneficial to service users but this may not always be the case. There may be a clash between the service or policy objectives and the individual, as we saw with the practice nurse. Professionals need to ensure that decisions about care and treatment offered are considered safe and effective (Box 3.4). In the community professionals need to consider the viewpoints, preferences and needs of patients and carers: it must not be assumed that patients’ and carers’
needs are the same (see Chapter 8).
Justice: Care must be equitable in terms of need and access to resources. In the community this may be a challenge as there will be unequal circumstances and resources affecting quality of care, for example, housing, access to family support or respite. This does not mean that equal time or care has to be allocated among service users but that there should be equitable provision relative to the assessed needs (Thompson et al., 2006). For example, Gerrish’s (1999) research showed that there was unequal access to district nursing services for ethnic minority patients because of the way district nursing services were aligned to different GP practices.
Professional practice requires decisions and choices to be made to achieve what is best and what is right – though sometimes such choices lead to a moral dilemma.
This is where there is conflict between moral principles, in choosing one principle in preference to another (Thompson et al., 2006). In the case of community mental health nursing, where a service user declines treatment but the nurse is aware of the potential harm if the patient does not take his medication, the principle of autonomy conflicts with beneficence, unless the patient is deemed incapable of making such a decision under the Mental Capacity Act (DH, 2005).
Having considered Miss Davies’ case regarding her autonomy, she may withhold consent to alternative accommodation or rehabilitation, which she is perfectly entitled to do, providing she is deemed capable of making such decisions. This is at the heart of giving informed consent to treatment. There are four important conditions that need to be in place for informed consent.